WHAT DOES "BORDERLINE" MEAN?

M. Gerard Fromm, Ph.D.

Austen Riggs Center

Box 962

Stockbridge, MA 01262

(413) 298-5511

Not for quotation without permission of the author.

WHAT DOES "BORDERLINE" MEAN?

Abstract

The word "borderline," unlike other clinical

descriptive terms, has no obvious affective or action referent

in the patient. This observation may help in understanding the

kind of misalliance so endemic to work with patients so

diagnosed. The possibility of who has what problem within an

analytic treatment, that it might seriously affect the frame of

the treatment, and that it might be an act of projective

identification by the analyst are explored. It is argued that

"borderline" pathology is not an entity, but rather the vast

developmental territory of severe personality disturbance, and

that Winnicott's theoretical contributions to an understanding

of the psychopathology of the dyad, particularly around boundary

development, are especially helpful.

WHAT DOES "BORDERLINE" MEAN?

Speaking of "the pathological side of my identity

confusion", Erik Erikson writes:

...no doubt it assumed at times what some of

us today would call a 'borderline'

character--that is, the borderline between

neurosis and psychosis. But then, it is

exactly this kind of diagnosis to which I

later undertook to give a developmental

perspective. And indeed, some of my friends

will insist that I needed to name this

crisis and to see it in everybody else in

order to really come to terms with myself.

(1970, p. 742)

This paper represents my own effort to "come to terms"

with the term "borderline." After an exhaustive review of the

literature on borderline psychopathology, Michael Stone (1986)

closes by saying, "I'm haunted by the dark suspicion that the

subject has gotten out of hand" (p. 432). By that he means that

"The borderline literature has swollen to a size too vast to be

digested by one anthologist" (p. 432), and certainly by any one

reader as well. I would like to consider something further in

this haunting: an unsettling impression that what we mean by

"borderline" has also "gotten out of hand," except perhaps as

the term "borderline" has become synonymous with something

having "gotten out of hand." My comments will address only

briefly the theoretical aspects of "borderline;" rather, my

focus will be on diagnostic and treatment practice, and on the

word "borderline" as an empty signifier and a complicated speech

act within a clinical context.

A few years ago, I was a discussant at a clinical case

seminar. After the presentation, and in the course of

discussion, I asked the group of about a dozen professionals, a

number of whom were quite experienced, how they would think

about the patient diagnostically; I added, "And let's think

about this without using the term 'borderline'." As might be

guessed, the group burst into laughter, which seemed both

anxious and relieved. But they then began to use clinical-

descriptive terms that had precise meaning in the data of the

presentation, and, even more importantly, with which the patient

herself would almost certainly have agreed on the basis of her

own subjective experience.

This is the place I would like to begin: with

phenomenology and with subjective experience. It's my guess

that, no matter how vast our literature on this topic, no

clinician has ever had a patient enter his or her office and

declare "I feel so borderline today," while we have all heard

people speak easily of "obsessing" or being "narcissistic" or

feeling "depressed" or "manic," "paranoid," "phobic,"

"hysterical," even "schiz-y." In other words, there seems to be

no ready or obvious affective or action referent in the patient

to which the word "borderline" gives a name.

Perhaps this observation means nothing more than that

this term "borderline" has not been in circulation long enough

to acquire a meaning to those suffering with it. Or perhaps it

only raises an old issue about the relationship of subjective

experience to the disease condition. Cancer patients don't feel

cancerous; they may or may not even feel ill. A schizophrenic

patient may be neither feeling nor behaving in a "schiz-y" way

to be accurately diagnosed; furthermore, diagnostic assessment

on that basis might be utterly inaccurate insofar as it does not

include recognition of a formal thought disorder. Indeed, one

of the earliest and most clinically captivating papers of the

borderline literature is Helene Deutsch's (1942) discussion of

the "as if" personality, in which she states clearly that these

forms of serious emotional disturbance and impoverishment "were

not perceived as disturbances by the patient himself" (p. 302).

Perhaps then, "borderline" patients do not have a complaint

which would lead them to speak to us with the kind of self-

descriptive statement of feeling or action referred to above.

Interesting as Deutsch's observation is, I'll for the

moment leave these considerations of a condition-without-a-

complaint and return to the problem of a name, "borderline,"

without an obvious referent. It seems to me that such a

diagnostic action, whatever else it might do at its most

professionally sensible and helpful level, involves the

clinician in telling the patient what he or she is, through a

name that can find no personal experience in the patient. It

therefore is an action which immediately shifts the locus of

authority away from the patient's potential complaint, with

whatever experience of distress may inform that, and into the

expert purview of the clinician. At its extreme, this

diagnostic action says: "What you are--namely borderline--is

something you do not, perhaps cannot, know introspectively or

experientially, but I can know about it."

Obviously, there are implications in this diagnostic

action, regardless of how silently it is apparently carried out,

for the frame of the treatment, insofar as this particular

statement, and the imbalances included within it, seem to

destroy from the beginning a genuinely psychoanalytic frame of

reference, while at the same time inflaming desires and

expectations in the patient to be the continued intensified

object of the analyst's power. If this action is not merely a

singular one, a potential mis-alliance, but a paradigmatic one

with these patients, can there be an effective treatment? It

was considerations like these that led George Vaillant to

entitle a recent paper "The Beginning of Wisdom is Never Calling

a Patient a Borderline" (1992).

By an analytic frame, I mean of course our structuring

of a relationship to the patient's inner process within which we

receive the patient's statement or inquiry about himself, in the

confidence that together we can come to know him. This

structuring of the relationship defines roles; starkly and

schematically outlining the locus of initiatives within this

role relationship, Andre Green (1978) has written that "No

analysis is conceivable in which, after the statement of the

fundamental rule, the analyst speaks first" (p.180). It is my

impression that our act of naming the "borderline" patient, with

a label he or she cannot know first-hand, is often in practice a

kind of "speaking first," a form of therapeutic mis-alliance,

setting into motion anti-analytic processes, processes which too

often lock the analyst into the position of, in Lacan's phrase,

the one who is "supposed-to-know" (Lacan, 1977; Muller, 1992).

This admittedly idiosyncratic train of thought could

be carried further! For example, this diagnostic action is most

usually carried out by a man upon a woman. It could thus be

seen as not only an act of professional imperialism, but also of

gender politics. And indeed, many treatments of "borderline"

patients in the long run come to look like disastrous marriages,

with the patient alternately struggling to liberate herself from

this meaningless name, the psychiatrist's name after all, while

also attempting to extract her due for having accepted it in the

first place. I vividly recall the absolute dread which a

patient of mine, a mental health professional, felt about the

possibility that I might think of her as "borderline"; by that

term, she seemed to mean both "crazy" and "too much." But more

than these meanings and more than her own anxious self-

diagnosis, it was the power of my potential diagnostic action my

patient truly dreaded, an action transferentially embedded in

her family's history of Eastern Mediterranean culture, within

which the social status of women was rigidly defined and deeply

toned by the male's unconscious fear.

There is more to be developed on this theme as it is

actually practiced, but I would like to leave considerations of

gender for now and return to the question of experience. It

seems to me that the only experiential referent for the term

"borderline" (unless we return to its grammatical use as a

qualifier, as in "borderline psychotic") is not in the patient

at all, but in the clinician. This experience may take the form

of a puzzlement as to whether or not one is facing a neurotic or

a psychotic phenomenon, but very often it is something more

urgent, something of a real dilemma in the clinician's embattled

psyche about whether he or she is meeting a need or a demand.

In other words, the clinician feels on a frontier of some sort,

placed there, indeed pushed there by a force from within the

patient and often dreadfully ill-at-ease with standing firm or

with stepping across.

My point of view here echoes the words of Robert

Knight in his classic 1953 paper on "Borderline States." "The

term 'borderline states'...conveys no diagnostic illumination of

a case other than the implication that the patient is quite sick

but not frankly psychotic.... Thus the label 'borderline

state', when used as a diagnosis, conveys more information about

the uncertainty and indecision of the psychiatrist than it does

about the condition of the patient" (p. 1). Nearly 40 years

later, George Vaillant (1992) writes: "I believe that almost

always the diagnosis 'borderline' is a reflection more of the

therapists' affective rather than their intellectual response to

their personality-disordered patients" (p. 120). He adds,

citing two studies: "That, perhaps, is why up to 90% of

patients diagnosed 'borderline' can also be assigned another,

usually more discriminating, Axis II diagnosis" (p. 120).

It seems to me that the history of work with

"borderline" patients, the more recent and very helpful

clarifications of Kernberg (1975, 1984) notwithstanding,

includes a substantial number of failed treatments which founder

on this uncertainty, which either never really get started or

drag out to disastrous conclusion as one side or the other of

this demand-need dilemma is enacted. Vaillant (1992) describes

these twin countertransference pitfalls as the therapist's

punitive and defensive setting of limits, on the one hand, or

the therapist's attempting to be a better mother than the one he

thinks the patient had, on the other. Neither help. In Lacan's

terms (1977), the psychotherapy of the "borderline", if it takes

off at all, is a psychotherapy in the imaginary order only, a

psychotherapy of desired but illusory images, cut off from and

ungrounded in a larger symbolic order of task and meaning, and

hence with no place for both parties to become subjects within a

matrix of social reality.

From this angle, the act of diagnosing the

"borderline" patient as such is, at its simplest level, a

statement that "this person has a borderline personality

disorder because that's where she places me," that is, at a

difficult dilemma about a boundary. Without this

countertransference awareness, the act of diagnosing borderline

phenomena becomes an act of projective identification by the

clinician, insofar as it simply exports an internal distressing

quandary into another person for purposes of relief and clarity.

(Recall Erikson's need "to see it in everybody else".) It mis-

recognizes who has what problem within this twosome, and thus

invites self-estrangement in both. In Vaillant's terms (1992),

"immature defenses have an uncanny capacity to get under the

skin" (p. 120); "the epithet 'borderline'" (p. 120) is a doomed

and disingenuous attempt to free the therapist from this

"contagion."

Before carrying this point further, I should perhaps

say that I do not believe that borderline psychopathology is an

entity, but rather a vast developmental territory, indeed

between psychosis and neurosis, eventuating upon failures of

development in a number of seriously psychopathological

disturbances of personality. Rosenfeld's (1979) descriptive

typology includes the psychotic character, the Kerbergian

borderline with "hardly any mental skin" (p. 197), the "as if"

personality, the traumatized patient, and the narcissistic

patient with disguised psychotic anxieties. The patients he

describes we easily recognize from our own clinical encounters,

and, though there is considerable overlap between his groupings,

there are also clear differences of emphasis in the forms of

defensive operations, in the kinds of affects struggled with and

in the transferences.

All of this I believe derives primarily from

developmental failure within that vast area defined so neatly by

Winnicott's work as the pathology of the two-some. In fact, a

simple arithmetical schema of development runs throughout

Winnicott's work: psychotic vulnerability has to do with that

phase of life within which the un-integrated infant comes, with

the help of the as-yet-unknown holding environment, to achieve

"unit status," becoming one person; neurotic illness has to do

with that phase of life within which the passions of a two-some

must be modulated by and re-organized to include a fundamentally

important third party. In between zero becoming one and two

becoming three is one becoming two, in fact a broad area of

potential enrichment and failure, each form of the latter, in

Tolstoy's words, "unhappy in its own way."

This is the area of personality disturbance, of

defenses against anxiety learned so early in life that they have

become fabric to who and how a person is. Their relative

immaturity pains others more immediately than they do the person

him- or herself, although shame (sometimes in the denied form of

shamelessness) is always a potential. Under serious stress,

these immature defenses come into full play. The person's

functioning reaches the "borderline" of psychosis (and thus the

word "borderline" to me implies primarily a level of severity of

the personality disturbance) insofar as, preoccupied with

survival within a two-person system, all considerations of what

Lacan (1977; Muller, 1993) would call "the third" disappear:

"the third" signifying the order of task, role, law, language,

society; in short, all that situates the two-person system in

something meaningfully larger.

It is to the issue of the two-some that I would now

like to return. My analysis of the "borderline", that is, of

the dilemma in the clinician leading him to name a condition in

the patient, a condition un-named in that way by the patient

herself, focuses on the interaction between two people, rather

than on the patient alone. To paraphrase Winnicott (1957), I am

suggesting that there is no such thing as a "borderline"

patient, only a couple interacting in a paradigmatic way.

Vaillant (1992) calls this couple "an enmeshed clinical dyad"

(p. 120-121). To continue with Winnicott, this interaction

bears striking similarity to the dynamic development of the

false self (1960), particularly insofar as the "spontaneous

gesture" from an evolving subject, that movement or feeling

coming naturally from the patient and recognized as his or her

own and as meaningful, is lost; in its place, there is

substituted a need-driven gesture from the other, in the

treatment situation the clinician's diagnostic action (and its

theoretical underpinnings), around which the subject organizes

for defensive purposes.

Here, in the link between "borderline" and the false

self, we connect with Deutsch's (1942) brilliant, original

formulation of the "as if" personality, and with Hilde Bruch's

(1978) work on the development of anorexia nervosa, itself not

an uncommon symptom in those labeled "borderline." Deutsch's

definitional statement is illuminating:

My only reason for using so unoriginal a label for the

type of person I wish to present is that every attempt

to understand the way of feeling and manner of life of

this type forces on the observer the inescapable

impression that the individual's whole relationship to

life has something about it which is lacking in

genuineness and yet outwardly runs along 'as if' it

were complete (p. 302).

In this one sentence, Deutsch anticipates the argument I am

putting forward; i.e., she pays conscious attention to the

naming or labeling process, she sees it as the result of

something forced inescapably on the clinician, and she

highlights something utterly inauthentic in something that looks

complete. Erikson might describe this seeming contradiction as

the failed effort to use multiple, partial, transient

identifications to solve the problem or the crisis of personal

identity.

It seems to me that our practice with "borderline"

psychopathology must address this issue of the false and the

true. So much from such a patient, and elicited by such a

patient, can feel utterly inauthentic, a dealing with smoke and

missing the fire; yet these patients also bring a true force

that must be reckoned with. Indeed, this force or this

intensity seems to be the bottom-line of the "borderline," at

least as I read DSM-III. I believe that the falsity in the

"borderline" represents that lack of "spontaneous gesture," of

play in the system, which would be signatorial of a secure, if

ailing, personality; and it also represents a defensive

adaptation to the system of care in which that person finds

herself.

Here one finds enormous potential for collusion, the

perhaps most crude if frequent example of which takes place in

psychiatric hospitals. In these systems, increasingly impinged

upon by externally imposed values, values of "cost containment,"

of "risk management," of "problem-oriented treatment plans,"

etc. (important values, perhaps, if integrated with treatment

values), a patient who speaks or acts "as if" she is suicidal

meets, all too infrequently, an "as if" response: a response,

analogous to the patient's pathology, based on external

identifications rather than on the true identity of the

hospital's treatment program; a response that looks "as if" it

is complete, except that it leaves out a genuine grappling with

the patient's communication and responsibility. This patient

may indeed be engaged in a serious manipulation of the system,

while acting out hidden needs or wishes (for example, to be

seen, or touched, or vengeful, or chosen over others), but too

often this kind of system has already defined itself as there to

be manipulated, as therefore not worthy of the patient's

respecting its function as a potential genuine container, and

even as itself engaging in manipulation of the patient to get

off some imagined hook of accountability.

Andre Green (1977) has written that "the borderline is

the problem patient of our time" and that "the mythical

prototype" is "no longer Oedipus, but Hamlet" (p. 15). But the

"to be or not to be" question raised at times so casually in the

system described above and responded to so collusively

represents a terrible miscarriage of communication and a chronic

depletion of the language and human resources with which to meet

the true problem. I will not elaborate here the treatment

philosophy, concretized in the totally open and voluntary

hospital setting in which I work, which grounds our efforts to

meet this problem therapeutically; nor would I want to suggest

that this particular hospital is immune to these dynamics.

Recently, as the hospital was working its way toward a major

leadership transition, our patients took to assembling, as a

group project turned to by various people throughout the day and

evening, huge jigsaw puzzles. And, as we have been lately

adapting ourselves, we hope sensibly, to various exigencies

facing hospitals currently, our patients have become concerned

about, as one feature of their effort to organize their

community life, the dangers of passive smoke. There are times

when I feel that the distinction between manifest and latent

obscures the equally important distinction between manifest and

blatant; our patients' wondering about how the parts fit

together into a single, coherent picture and their worrying

about the un-seen effects of everything we are all quietly,

regularly breathing in seem like essential communications in

their basic self-preservative effort to correct any warp

developing in the holding environment they so need. The only

question is: can these communications be honestly received? To

the extent that the treatment personnel are "supposed to know,"

this necessary receptive capacity, and the vitalizing dialogue

it initiates, are seriously compromised.

For treatment personnel or for the individual

practitioner, a patient's acting out around the magical word

"suicidal" is again their being placed, with urgency, on a

border: between need and demand, often between management and

interpretation. For the patient, it is many things: perhaps a

response to the threat of being lost, but perhaps also, as Ghent

(1992) points out, a response to the threat of being found in

the treatment. The defensive function of false-self adaptation

is to hide the true self, that core of personality seriously

vulnerable to "primitive agonies" if ever it is allowed another

"regression to dependency." All of these are Winnicott's terms.

As Ghent suggests, we might see the demand or neediness of the

patient, a barrage of affectivity so potentially dis-orienting

to the therapist, as confounding and hiding the real need, a

need threatened with potential exposure, as much to the patient

herself as to her therapist. The therapeutic task is the

sustaining of this paradox, the validation of need without

gratification of neediness, the holding, rather than splitting,

of different emotional parts or points of view. For Ghent,

"borderline" acting out is the result of real environmental

failure and results in a tendency to ab-use the object rather

than use it in the important sense outlined by Winnicott (1971a)

in one of his major and final theoretical statements.

In this paper Winnicott describes the developmental

movement from what he calls object-relating, that early phase of

one becoming two when the other is only perceived on the basis

of projections and has only self-object or subjective status, to

object-usage, the phase of two people, recognized as separate

and different, though related. This is the object objectively

perceived, available potentially for use according to its own

inherent properties. This major developmental move, one feature

of what Winnicott calls "realization," occurs through the

child's aggression and the other's survival of that aggression

without retaliation. In the child's act of destroying the

fantasy-other, that which survives must be a real other, and

inter-subjective living becomes a possibility. For Winnicott,

the function of aggression in the finding of reality, and the

belief that only the true self can feel real, are old themes.

His "use of the object" concept sums up for him the major

differentiation and integration achievements of the weaning

process: the me from the not-me, fantasy from reality, the

mother of care as one with the mother of hunger, libidinal

ruthlessness integrating with reparative capacities.

For the patient presenting us with the "borderline"

problem, we can often see within this false-self defensive

enactment an enormously compromised appreciation of reality

coordinate with major difficulties with aggression. As Knight

(1953) writes of "borderline states," "The break with reality,

which is an ego alteration, must be thought of not as a sudden

and unexpected snapping, as of a twig, but as the gradual

bending as well..." (p. 3) One recurrent clinical feature with

some "borderline" patients is deeply aggressive behavior wrapped

in sentimentality, a chronic bending of reality which once again

invites, even plays upon, the clinician's collusion and choosing

sides. But sentimentality so suffused with aggression both

represents something and does something, and the representation

can easily be lost in the doing, or vice versa. It conjures up

an image of a good but lost object-relationship, something

evanescent, nostalgic, childishly purified of anything

disruptive, fragile, and not fully real. But the clinician also

feels the aggression and can choose to deny it, as the patient

seems to, or to push it back into the patient and thus become

the disruptive, destructive intruder into the sentimentalized

internal relationship. This is the "borderline" place and

pitfall. Both parts are true: there is a lost love

relationship in this sentimentality, perhaps to a part of the

self (Bollas, 1982), as well as to an other, and Winnicott's

statement in his classic paper "Hate in the Countertransference"

(1958) also holds: that a person cannot tolerate "the full

extent of his own hate in a sentimental environment. He needs

hate to hate" (p. 202).

Andre Green (1977) and Harold Searles (1986) have, in

very different ways, highlighted the use of the

countertransference with borderline patients. Green returns us

to a concept of "borderline" inherent in Freud's definition of

instinct:

an 'instinct' appears to us as a concept on the

frontier between the mental and the somatic, as the

psychical representative of the stimuli originating

from within the organism and reaching the mind, as a

measure of the demand made upon the mind for work in

consequence of its connection with the body.

(Freud, 1915, p. 121-122, italicized by Green, 1977, p. 30) For

Freud, the work of the mind required optimal frustration. Green

(1975) accents this condition differently; the work of the mind,

or the capacity for thought, depends on the experience of

tolerable absence, with its implication of potential presence.

An object too much there or too utterly lost destroys the

conditions for thinking.

Perhaps this underlies the "borderline" paradigm.

(See also Fonagy, 1991) That transformation from body to mind,

that "borderline" which Freud called instinct, does not happen

in a two-person psychology fraught with serious loss or

intrusive affective presence. Instead of movement across a

boundary, there is a split or barrier. Affectivity is simply

evacuated, and, if there is a treatment situation, evacuated

into the other, "forced upon us" (1942, p. 302) as Deutsch said.

This other may or may not be able to do, and enlist the

patient's assistance in doing, the work of transformation within

himself. If he cannot, some variant of counter-projective

processes must occur, the putting of the "borderline" back into

the patient and holding it at arms length. If he can, there is

an incremental sense of the reliability of the container and the

tangibility of a content. It is this failure of metabolization

in the primary other that Rosenfeld (1979) and many others see

as central to this area of psychopathology. Winnicott writes:

"In the extreme of a borderline case, everything boils down in

the end to what I have tried to describe as the survival of the

analyst" (1987, p. 181); by this, Winnicott means surviving as

an analyst, without retaliation and with technique and the

analytic setting intact. Intact technique would mean, at least

ideally, the analyst's ability to deal with his "borderline" or

"frontier" problem: that is, to make that transformation from

his body (given what the patient is bringing to it) to his mind

which we call interpretation, delivered, if at all, with that

gracefulness and courtesy so thoroughly a part of Winnicott's

clinical care (1989).

In the Austen Riggs Center's long-term follow-up study

(Plakun, 1991), one set of results had to do with patients

diagnosed as "borderline;" two variables, one historical, the

other clinical, were predictors of good outcome: the absence of

a parental history of divorce and the presence of self-

destructive acting out during the course of treatment in our

hospital. If Erikson (1961) was accurate when he said that it

is the task of the family, "in one of its exemplary forms," to

help the child "gradually delineate where play ends and

irreversible purpose begins" (p. 156), perhaps the converse is

also true: families that do not survive create more severe

"borderline" difficulties, including a constriction of the

reversible processes of play, in confusion with something more

irreversible and purposeful. And perhaps also the treatment

environment must be tested and used fully and survive in a vital

working way, in order for the patient to finally and securely

achieve these differentiations, along with the "shrinking to

life-size," in Harry Stack Sullivan's phrase, so joyfully

experienced upon being survived. This is the task of

establishing real and helpful boundaries, boundaries that are

not barriers, but that establish "edges" for both interchange

and contact.

Winnicott (1971b) once wondered what would happen if

the baby looked into his mother's eyes and did not see himself?

What I suspect can happen is the simultaneous establishment of

no-boundary and of enormous gap, the gap between an image held

urgently by the mother and the child's felt potential in and of

himself. The imposition of the former upon the latter is the

boundary violation. Shapiro's (Shapiro et.al., 1989) research

on the contradictory, projectively-toned images of the child-at-

risk held by each of his parents might lead to the same

conclusion. Perhaps the "borderline" is the child's

internalization of the no-man's-land between his parents, or

between image and inner experience, especially as parental

figures receive and react to his developing personality and

affectivity. This gap may also be the formative precursor of

the fault lines in the treatment situation, which the patient

must actively exploit rather than passively suffer. The actual

meaning in the word "borderline," which has been the subject of

this paper, may most simply reflect the problems of people

around borders or boundaries. For some people, the earliest

efforts at contact and at separateness have encountered

unbridgeable gaps, external then increasingly internal, brought

both hopefully and assaultively to the therapist, who feels, in

the words of Francoise Davoine, "the paradox of frontiers":

"that they are never more present than when they are broken by

an invasion" (1989, p. 595).

The "splitting" so regularly described as basic to the

"borderline" condition fits in here. It represents the failed

integration, and then the exploited dis-integration, of the

unsuccessful depressive position. Two fully developed and fully

perceived people do not emerge from this developmental

landscape. Rather, two partial people do, each alternately

deprived by and falsely enriched by projective processes, and

each needing the other for conflictual equilibrium. Most

importantly, hate is not saddened by love, nor is love matured

by hate. Instead, the intensity of affects related to loss and

to intrusion mitigates against such ordinary integrations and

against the capacity for concern as well, which would be its

natural outcome (Winnicott, 1956b). There is thus also

superego pathology: a conscience which cannot accurately gauge

the effect of behavior and needs interpretation from the

countertransference, and an ego ideal which knows it needs, but

is otherwise without signifiers for, a real and truly meaningful

grounding in something larger.

Hamlet, like Dr. Stone, was haunted by dark

suspicions. Like the false self, he was invited to live out a

lie. Like trauma victims, which some research links to

"borderline" functioning, his life, as we know it, begins after

a death. He both feigns madness and actually carries the

madness of overwhelming knowledge and feeling. While he places

others in that quandary Deutsch describes--What is wrong with

him?--he himself struggles with abandoning himself to a rage

both vengeful and random, since all is already lost. He has no

"other." Becoming an "other" for a patient so injured is not a

task to be taken lightly. It is to meet both loss and rage, in

the patient and in oneself. It requires a deeply and a well-

grounded two-person perspective, and a steady effort to find the

pulse of integrity within the shifting affective and defensive

energies of the relationship. And, like the depressive position

itself, that first paradigm of two-person relatedness, it

challenges us to bring together empathic care with something in

the direction of ruthlessness. Winnicott (1987) will have the

last word:

If the patient feels that it is worth doing, it is

worth doing, in spite of the fact that every stage

which could be called an advance brings the patient

into closer contact with pain. In other words, the

patient gives up defenses, and the pain is always

there against which the defenses were organized. This

kind of work, as I have pointed out in talking about

the treatment of psychotic children, could be

described as cruel. When it succeeds, of course, the

cruelty and the suffering are forgotten. p. 181)

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M. GERARD FROMM, Ph.D., is on the Senior Staff of the Austen

Riggs Center and the Director of its Therapeutic Community

Program. He is the co-editor, with Bruce L. Smith, Ph.D., of

The Facilitating Environment: Clinical Applications of

Winnicott's Theory. His current writing projects include a

consideration of the role of creative activity in psychological

development, following Marion Milner's work, and a consideration

of the role of historical catastrophe in psychotic development.